Curr. Oncol., Volume 16, Issue 4 (August 2009) – 11 articles

Primary non-Hodgkin lymphoma (nhl) of liver is a very rare malignancy. Here, we report the case of a 65-year-old man who presented with constipation and right groin pain of 2 months’ duration. A computed tomography (ct) scan of the abdomen incidentally detected multiple hypodense nodules in both lobes of the liver. Diagnosis of primary nhl of liver was made using ultrasound-guided biopsy. Extensive investigations—which included bone marrow biopsy; fluorescence in situ hybridization; flow cytometry; ct scan of chest, abdomen, and pelvis; and whole-body positron-emission tomography—showed no involvement of bone marrow, lymph nodes, spleen, or any other organ. The patient is currently being treated with a chop-r (cyclophosphamide–doxorubicin–vincristine–prednisolone/rituximab) regimen. The case has many unique features, including normal liver function tests, especially that for lactate dehydrogenase; no type B symptoms; and negative serology for viruses. The case demonstrates that primary hepatic lymphoma should be considered in the differential diagnosis of space-occupying liver lesions in presence of normal levels of alpha-fetoprotein and carcinoembryonic antigen. The literature is extensively reviewed. Full article

Hemangiopericytoma is a malignant vascular tumour of soft tissue. Microscopically, the tumour shows tightly packed cellular areas surrounding thin-walled branching blood vessels. Traditionally these tumours are treated using wide surgical excision. Only a very few cases of hemangiopericytoma of the prostate have been described worldwide. The feasibility of managing such a case with a combination of conservative surgery and adjuvant anti-malignancy treatment is unexplored. Here, we report a case of hemangiopericytoma of the prostate treated with local excision, with preservation of prostate, followed by adjuvant radiotherapy (40 Gy in 20 fractions to pelvis followed by 24 Gy in 12 fractions as boost to prostate) and chemotherapy (doxorubicin and iphosphamide). Post-treatment computed tomography scan after 4 weeks showed regression of pelvic lymph nodes and a normal-appearing prostate. Levels of serum prostate-specific and carcinogenic embryonic antigen were normal throughout the period of treatment. To date, follow-up has been uneventful, except for occasional bouts of diarrhea. We conclude that conservative surgery followed by adjuvant radiation and chemotherapy, with subsequent close follow-up, may adequately control localized disease in selected cases of hemangiopericytoma of the prostate. The role of conservative surgery in tumours located at other sites has yet to be defined. Full article

Background: Cancer patients frequently use alternative therapies. Two follicular lymphoma patients who had objective tumour regression after taking Devil’s Claw without cytotoxic therapy are reported here. Methods and Results: Patient 1 presented with coexistent immunoglobulin G plasma cell dyscrasia and stage iiia lymphoma (nodes 5 cm in diameter). Computed tomography scan 10 months later showed partial regression. On enquiry, it was learned that the patient was taking Devil’s Claw and Essiac (Essiac Products Services, Pompano Beach, FL, USA). This patient later developed overt myeloma, at which time he stopped the herbal supplements and underwent high-dose chemotherapy and stem cell transplantation, since which no lymphoma progression has occurred. Patient 2 presented with stage iiia lymphoma (nodes 2.5 cm in diameter). He learned of patient 1 through our lymphoma patient support group and started Devil’s Claw. Computed tomography scan 11 months later showed decreased adenopathy and splenomegaly, which has been sustained for 4 years. Discussion and Conclusions: Devil’s Claw tuberous root has anti-inflammatory properties, probably through suppression of cyclooxygenase 2 (cox-2) and inducible nitric oxide synthase expression. There are no prior reports of anticancer activity. Inhibition of cox-2 has a role in colon cancer prevention, has been implicated in lymphomagenesis, and is associated both with lymphoma stage and with response to treatment. However, spontaneous regression in lymphoma has been reported in 16% of patients in one series, of whom none were on herbal medications or cox-2 inhibitors. The key issue in both these patients is whether disease regression was “spontaneous” or causally related to therapy with Devil’s Claw. The timing of the response suggests a positive effect. Further investigation is warranted, preferably with a cox-2 inhibitor of known purity. Full article

The discovery that rna interference (rnai) and its functional derivatives, small interfering rnas (sirnas) and micro-rnas (mirnas) could mediate potent and specific gene silencing has raised high hopes for cancer therapeutics. The prevalence of these small (18–25 nucleotide) non-coding rnas in human gene networks, coupled with their unique specificity, has paved the way for the development of new and promising therapeutic strategies in re-directing or inhibiting small rna phenomena. Three strategies are currently being developed: (1) De novo rnai programming using synthetic sirnas to target the expression of genes; (2) Strengthening or recapitulation of the physiologic targeting of messenger rnas by specific mirnas; (3) Sequence-specific inhibition of mirna functions by nucleic acid analogs. Each strategy, currently being developed both in academia and in industry, holds promise in cancer therapeutics. Full article

Purpose: Radiotherapy for oncologic emergencies is an important aspect of the management of cancer patients. These emergencies—which include malignant spinal cord compression, brain metastases, superior vena cava obstruction, and uncontrolled tumour hemorrhage —may require treatment outside of hospital hours, particularly on weekends and hospital holidays. To date, there remains no consensus among radiation oncologists regarding the indications and appropriateness of radiotherapy treatment on weekends, and treatment decisions remain largely subjective. The main aim of the present study was to document the incidence and indications for patients receiving emergency treatment on weekends or scheduled hospital holidays at a single institution. The secondary aim was to investigate the compliance of such treatment with the institution’s quality assurance policies, both local and provincial. Methods: From 1 September 2002, to 30 September 2004, patients being treated over weekends (defined as commencing at 6 pm on a Friday and concluding at 8 am of the next scheduled workday) and hospital holidays were retrospectively identified using the Oncology Patient Information System scheduling module. Relevant patient data—including patient age, sex, primary cancer site, specific radiation field, rationale for treatment, referring hospital, total treatment dose, radiation dose fractionation, inpatient or outpatient status, and duration of treatment—were collected and subsequently analyzed. Comparison to local policy was performed subjectively. Results: Over the 2-year period, 161 patients were prescribed urgent radiotherapy over a weekend or on a hospital holiday. Of this cohort, 68% were treated on both Saturday and Sunday, 22% on Saturday alone, and 10% on Sunday alone. Most patients presented with lung (31%), prostate (18%), and breast cancer (17%). The top reasons for referral for emergency weekend treatment included spinal cord compression (56%), brain metastases (15%), and superior vena cava obstruction (6%). Most of the indications for treatment generally followed the quality assurance policies implemented both locally and provincially. Conclusions: Patients treated over a weekend or on a hospital holiday were generally found to be treated with appropriate intent. Most treatment indications within this study both complied with provincial policy and showed a pattern of care similar to that seen in other studies in the literature. Local policy appears to be robust; however, policy improvements may allow for more cohesiveness across radiation oncologists in patterns of care in this important group of patients. Comparisons with practice at other institutions would be valuable and also a key step in developing sound guidelines for all members of the radiotherapy community to follow. Full article

Background and Purpose: Extended-volume external-beam radiation therapy (rt) following esophagectomy is controversial. The present prospective study evaluates the feasibility of extended-volume rt treatment in high-risk esophagectomy patients with a cervical anastomosis receiving postoperative combined chemoradiation therapy. Patients and Methods: From 2001 to 2006, 15 patients with resected esophageal cancer were prospectively accrued to this pilot study to evaluate the adverse effects of extended-volume rt. Postoperative management was carried out at London Regional Cancer Program. Eligibility criteria were pathology-proven esophageal malignancy (T3–4, N0–1), disease amenable to surgical resection, and esophagectomy with or without resection margin involvement. Patients with distant metastases (M1) and patients treated with previous rt were excluded. All 15 study patients received 4 cycles of 5-fluorouracil–based chemotherapy. External-beam rt was conducted using conformal computed tomography planning, with multi-field arrangement tailored to the pathology findings, with coverage of a clinical target volume encompassing the primary tumour bed and the anastomotic site in the neck. The radiation therapy dose was 50.40 Gy at 1.8 Gy per fraction. The rt was delivered concurrently with the third cycle of chemotherapy. The study outcomes—disease-free survival (dfs) and overall survival (os)—were calculated by the Kaplan–Meier method. Treatment-related toxicities were assessed using the U.S. National Cancer Institute’s Common Toxicity Criteria. Results: The study accrued 10 men and 5 women of median age 64 years (range: 48–80 years) and TNM stages T3N0 (n = 1), T2N1 (n = 2), T3N1 (n = 11), and T4N1 (n = 1). Histopathology included 5 adenocarcinomas and 10 squamous-cell carcinomas. Resection margins were clear in 10 patients. The median follow-up time was 19 months (range: 3.5–53.4 months). Before radiation therapy commenced, delay in chemotherapy occurred in 20% of patients, and dose reduction was required in 13.3%. During the concurrent chemoradiation therapy phase, 20% of the patients experienced chemotherapy delay, and 6.6% experienced dose reduction. No patient experienced treatment-related acute and chronic esophagitis above grade 2. Disease recurred in 40% of the patients (6/15), and median time to relapse was 24 months. No tumour recurred at the anastomotic site. The median dfs was 23 months, and the median os was 21 months. Conclusions: Extended-volume external-beam rt encompassing the tumour bed and the anastomotic site is feasible and safe for high-risk T3–4, N0–1 esophageal cancer patients after esophagectomy. Full article

The concept of organ-preserving therapies is a trend in modern oncology, and several tumour types are now treated in this fashion. Trimodality therapy consisting of as thorough a transurethral resection of the bladder tumour as is judged safe, followed by concomitant chemoradiation therapy, is emerging as an attractive alternative for bladder preservation in selected patients with muscle-invasive bladder cancer. Long-term data from multiple institutional and cooperative group studies have shown that this approach is safe and effective and that it provides patients with the opportunity to maintain an intact and functional bladder with a survival rate similar to that for modern radical cystectomy. Full article

The role of targeted therapies in the treatment of women with breast cancer has been rapidly evolving. Trastuzumab, a monoclonal antibody against the human epidermal growth factor receptor 2 (her2), was the first her2-targeted therapy that clearly demonstrated a significant clinical benefit for women with her2-overexpressing metastatic breast cancer (mbc). However, in recent years it has become increasingly apparent that, when trastuzumab is used in the first-line setting in combination with chemotherapy, most women eventually develop progressive disease. Determining the treatment options available to women who have progressed while on trastuzumab therapy has been hampered by a paucity of high-quality published data. In addition, with the standard use of trastuzumab in the adjuvant setting (for eligible her2-positive patients), the role of anti-her2 agents for patients who experience a breast cancer relapse has become a clinically relevant question. This manuscript reviews current available data and outlines suggestions from a panel of Canadian oncologists about the use of trastuzumab and other her2-targeted agents in two key mbc indications: (1) Treatment for women with her2-positive mbc progressing on trastuzumab (that is, treatment beyond progression); (2) Treatment for women with her2-positive mbc recurring following adjuvant trastuzumab (that is, re-treatment). The suggestions set out here will continue to evolve as data and future trials with trastuzumab and other her2-targeted agents emerge. Full article

Objective: We aimed to describe the perceptions of health care providers concerning patient and health care provider strategies to limit out-of-pocket costs for cancer care. Methods: We conducted semi-structured interviews with 21 cancer care providers (nurses, social workers, oncologists, surgeons, pharmacists, and dieticians) in Newfoundland and Labrador. Results: Patients try to minimize costs by substituting or rationing medications, choosing radical treatments, lengthening the time between follow-up appointments, choosing inpatient care, and working during treatment to minimize loss of income. Providers respond to the financial concerns of patients by helping them to access financial assistance programs, by changing chemotherapy and supportive drug prescriptions, and by shortening radiation treatment protocols. They admit patients to hospital and arrange follow-up with physicians closer to a patient’s home. Conclusions: Out-of-pocket costs resulting from cancer care are incurred at all phases of treatment and follow-up. These costs are substantial concerns for some patients and their health care providers. Encouraging communication between patients and their providers is needed to identify individuals at risk and to safely modify care plans. Tele-oncology and public drug, medical travel, and leave programs are needed to ensure that patients are better able to afford the costs related to cancer care. Full article